Editorials

Treating Fibromyalgia: Science vs. Art

In this issue of American Family Physician, Millea and Holloway1 provide an excellent overview of the treatment of fibromyalgia. As the authors indicate, it is important for primary care physicians to be able to recognize this entity because it is a condition that occurs commonly, especially in the primary care setting.

Unfortunately, not all health care professionals, primary care or otherwise, want to diagnose and manage fibromyalgia. Some physicians dismiss the “label” of fibromyalgia, usually because the diagnosis is based on self-reporting of symptoms and no objective findings or diagnostic tests legitimizing the condition. It is unclear why fibromyalgia is sometimes “singled out” in this regard. However, approximately 40 percent of patients seen in the primary care setting have symptoms with no identifiable cause, and most practitioners are comfortable making and managing other symptom-based diagnoses such as migraine and tension headache, irritable bowel syndrome and dysmenorrhea.2

Other practitioners accept the fibromyalgia construct but view these patients as “difficult.” Patients with fibromyalgia or similar conditions may be considered difficult because physicians are unable to make them feel better, their demands exceed physicians' capabilities or both.

For these reasons, reviews such as the one by Millea and Holloway1 are helpful because they appropriately focus on the latest scientific evidence regarding mechanisms and treatment. Physicians who see large numbers of patients with fibromyalgia may be of most help by educating practitioners on the “art” of diagnosing and managing this disease. I have provided a series of suggestions for diagnosis and management:

Diagnosis. Try not to get stuck on labels or rigid criteria. The savvy practitioner realizes that labels such as fibromyalgia may be helpful to some patients, whereas such labels are unnecessary and could even be harmful to others.

In essence, fibromyalgia represents a sensory amplification syndrome. Individuals experience pain that is not caused by damage or inflammation in the periphery but is rather associated with a central defect in pain processing. Fibromyalgia is only the “tip of the iceberg” for conditions characterized by pain that is not due to peripheral inflammation or damage. Many individuals with chronic peripheral pain (e.g., low back pain, arthritis) or visceral pain (e.g., irritable bowel syndrome, interstitial cystitis, chronic pelvic pain) have similar central mechanisms that amplify or exacerbate pain.3 This process may be called fibromyalgia or may go unnamed, but it is important to recognize this phenomenon because “central pain” responds to different interventions than “peripheral pain.” To expand this construct even further, most individuals with chronic, unexplained somatic symptoms other than pain (fatigue, cognitive difficulties) probably also fall in this same spectrum and respond to similar interventions.4

If fibromyalgia is viewed as the musculoskeletal end of a much larger continuum of chronic symptoms that are not due to a peripheral cause and do not respond to standard therapy, then understanding this spectrum of illness can help in the management of a substantial percentage of patients who are seen in primary care.

Management. The management of fibromyalgia is not amenable to a single 15-minute appointment. Once this diagnosis (or a similar one) is considered, the practitioner should schedule a prolonged visit or a series of visits. The time invested in the beginning of the physician-patient relationship pays tremendous long-term dividends for the practitioner and the patient. It is necessary to spend this time in order for the physician to understand precisely what is bothering the patient and for the patient to understand the goals of (and rationale for) treatment. During these visits, it is important to explore the symptoms that the individual is experiencing, the impact of the disorder on the patient's life, the patient's perception of what is causing these symptoms and the stressors that may be exacerbating the illness.

Once these goals have been accomplished, the patient should be educated about the nondestructive nature of this condition, as well as the fact that meaningful improvement rarely occurs without active participation on the patient's part—the patient must know that there is no “magic bullet” for treatment.

Treatment. Make maximal use of nonpharmacologic therapies. At present, the treatment of fibromyalgia approximates that of hypertension 30 years ago: there were a modest number of marginally effective drugs for hypertension at that time; typically, the patient was told to lose weight and restrict sodium intake. Our current therapy for fibromyalgia is similarly limited, and the nonpharmacologic interventions that are frequently necessary include some form of aerobic exercise and education or formal cognitive behavior therapy (CBT).

Education about these interventions is best administered in a stepped approach. For example, patients can be told to begin a low-impact exercise such as walking, five to 10 minutes per day three to four days per week, and slowly increase the time by one to two minutes per week as tolerated. If necessary, this can be done under the supervision of a therapist, and/or in an aquatic setting. With respect to CBT, simple self-help books, classes such as those organized by the Arthritis Foundation and informational Web sites are adequate for many patients. For refractory patients, group CBT, or even individual therapy, is necessary.

In practice, it is widely felt that these interventions are most effective when combined with symptom-based pharmacologic therapy, although there are no data to support this approach. In addition to the medications mentioned by the authors of the article in this issue,1 other classes of medications that may be effective include newer classes of antidepressants (e.g., those that have more prominent norepinephrine and dopaminergic effects), gabapentin (Neurontin) or tramadol (Ultram) for the management of pain and trazadone (Desyrel) or zolpidem (Ambien) to improve sleep.

With this expanded armamentarium, the caring practitioner can effectively manage the majority of patients with fibromyalgia. Hopefully, identifying these conditions earlier in primary care and intervening before the chronic nature of the condition leads to dysfunction and disability will ultimately lead to fewer numbers of the “difficult” patients that challenge us all.

Daniel Clauw, M.D., is associate professor of medicine and orthopedics, chief of the division of rheumatology, immunology and allergy and scientific director of the Georgetown Chronic Pain and Fatigue Research Center, Washington, D.C.